Auckland City Hospital in Grafton. Photo / Jason Oxenham
Auckland City Hospital in Grafton. Photo / Jason Oxenham
In 1985 I was appointed as a neurologist at Auckland Hospital. Patients would be referred to the hospital service, or come via the Emergency Department, and we would provide the best care possible. They would then return to the community to be cared for by their GP and a rangeof community-based health care providers.
At that time health services were provided under the umbrella of 14 Area Health Boards. Since then there have been three health reforms, all politically driven and expected to correct the problems under the previous structures. Four Regional Health Authorities (RHAs) with 23 Crown Health Enterprises (CHEs) were established in 1993 by the National Government. The concept of “for-profit competitive” hospital practice was anathema to those of us in public hospital service and many dictates of this new order were ignored by us in the interests of good patient care. In 1997 the National-NZ First coalition replaced the RHAs with a single Health Funding Authority and the 23 CHEs were replaced by 24 Hospital and Health Services. In 2000 the Labour-Alliance coalition created 21 District Health Boards (DHBs) and Primary Health Organisations (PHOs).
Now we have a new health reform underway. To think that yet another reform will be successful is indeed the triumph of optimism over experience. This reform envisages a new national health service, providing better and more equitable care, and reducing costs by centralisation. Once again, it has been politically driven. The arguments for doing this have included unnecessary duplication of nonclinical services and improving inequity of care on a geographic basis. An excellent review by Heather Simpson, recommending the reduction of DHBs to eight, was shelved, in favour of a single national agency with regions and districts.
The new health reforms are underway and are taking on a substantial complexity. Instead of focusing only on the major issues, it seems that the whole of the health service is going to be turned upside down, driven by philosophical views of some of those in charge, rather than practical provision of good healthcare.
The first tranche of changes has involved non-clinical staff and has got off to a rocky start. Many have been told that their positions have been disestablished. Some of these redundancies are to reduce “duplication”. Others represent a change in philosophical views driven more, it seems, by empire-building than common sense. Some didn’t know they were being “disestablished” until told on a group webinar, and their managers had no prior information about these moves so were unable to provide support for distressed long-term employees.
This evidence of lack of trust between those driving the change and the current clinical and other managers is shameful, and does nothing to ensure these reforms can continue with the support and respect of those “on the ground”.
While there is a consultation period of a month, the best of those disestablished won’t wait around in the hope of “reestablishment”, but will simply find employment elsewhere. This process has been inhumane and reflects very badly on a new structure that is supposed to improve clinical care. There will likely be many personal grievances arising from a flawed process, just when support and goodwill will be needed to drive home the changes.
An example is the interference with the highly regarded and successful research structure at Auckland City Hospital. The manager of this service has been disestablished, without any consultation with those involved in the service, or her clinical manager. Research at Auckland City Hospital, along with the Academic Health Alliance with the School of Medicine, is the powerhouse of hospital-based clinical research. There are robust processes for assessment, review and oversight of research, along with sound financial management. It appears this is to be dismantled in favour of a remote regional process. This will not satisfy any requirement for better and more efficient healthcare but will damage goodwill and morale amongst clinical staff.
Dr Richard Frith is a semi-retired neurologist and clinical neurophysiologist in Auckland. Photo / supplied
There are major issues that require urgent attention. Perhaps the health reforms should focus on these, get them under control, and then worry about other less important issues.
1. Support and enhance primary care
General practice is the most complex of specialties in medicine. We expect our GP colleagues to assess many patients, manage most of them in the primary care setting, and send those with urgent or complex issues to secondary or tertiary care. They are the gateway to the health system. Without high-quality general practice, healthcare provision will be substantially disadvantaged. There have been suggestions that GPs could be replaced by other practitioners using protocols. General practice should be GPs and nurse practitioners working together as a team, each at the top of their scope, rather than in competition, as each has equally valuable, though not interchangeable, roles. General practitioners have been dealt with dreadfully over the last few years especially during the Covid pandemic.
What is more, pay parity has been agreed for nurses in hospital-based settings, but GP nurses were not included in that – another example of the disdain directed at general practice. As a consequence GPs have become disillusioned, and many have become burnt out.
General practice is currently not seen as an attractive specialty amongst young medical graduates. The average general practitioner age is increasing and some are contemplating early retirement or moving to more remunerative and less stressful positions in health. Without urgent attention, there will be substantial problems.
The solutions seem straightforward. Firstly there needs to be an urgent increase in the number of medical school places. Secondly, significant exposure to general practice and enhancements to encourage a career in general practice should be a priority during medical training. Thirdly the current GP workforce should be recognised for the important work it does in the community, with appropriate respect from health authorities and enhanced remuneration.
2. Rationalise access to secondary and tertiary healthcare
The issue of “postcode” medicine refers to those generally distant from hospitals who have less access to high-quality care, or differences in care depending on which area the person is resident. It should not mean that the services need to be delivered “close to home”. The solution is in making sure that those, particularly from remote regions, wait no longer for care than those in urban areas. This is simply a planning issue at hospital level. Enhanced patient travel and accommodation for those from remote areas to ease the burden of travel is again an easy planning issue.
Many of the high technology/ expensive services are provided in more locations than ideal or appropriate for a population of five million. Fewer centres with greater numbers of specialists and support staff improve patient care, improve ability to recruit to new positions, and enable quality on-call services.
There are, for example, five neurosurgical units in New Zealand. Some of the development of these high-tech services has been politically driven; the retention of the neurosurgical unit in Dunedin, for example, was driven by public protest, rather than rational provision of healthcare. A combination of fewer neurosurgical units (three for New Zealand) with high-quality transportation and accommodation for those from remote areas, will result in far better care.
A nationally-coordinated acute stroke service, with two or three centres for stroke clot retrieval, will enhance care for all who need the service.
Again, investment in fast interhospital transfer is the key to success. Most patients I believe will happily trade the inconvenience of travel and separation from family for higher quality better outcome services.
Magnetic resonance imaging (MRI) brain scans displayed on a screen on a doctor's desk.
4. Keep politics out of the process
Many decisions about the provision of health care in the past have been politically driven, rather than rationally planned. The location of North Shore Hospital is a good example of a hospital built in the wrong place, to satisfy the whims and needs of a local MP. The failure of multiple health reforms reflects political imperatives rather than careful planning.
5. Rapidly address clinical workforce issues
There is no doubt that we are facing a crisis in healthcare provision in New Zealand. Nurses are increasingly finding overseas positions more attractive. While many thousands of our nurses have recently registered for practice in Australia, the immigration process for nurses wishing to come to New Zealand has been hopelessly flawed and only a handful have been employed from other countries. There are serious workforce issues in medical staffing at trainee and specialist level, driven by understaffing, burnout, disillusionment and better professional opportunities overseas. This will all be worsened unless any reform is well-managed and makes common sense.
6. Central procurement of equipment and medical supplies
In the past, multiple CHEs and then DHBs have made their own decisions about purchasing, including the purchasing of high-cost technology. A national-based purchasing agency will be an essential part of any reform. This process was already under way before the current health reforms.
7. One national electronic clinical record system
This needs to be accessible by all health professionals, and probably also patients. At present, there are multiple different clinical records systems. While removing legacy systems and replacing them with one standard record system will be expensive, it is essential.
8. Reduce duplication in nonclinical areas
There has been an extraordinary explosion in the number of non-clinical staff in all of the DHBs. The response in these reforms seems to be the removal of a whole tranche of “local” experts and their replacement with a national structure. What has been missed is that locally-based and accountable HR, accounting, legal advice and other areas of nonclinical support are essential for success at a local or regional area. The art in reducing staff numbers will be to ensure that local services can still be provided, but that there is no unnecessary duplication on a nationwide basis.
9. Clinical input into decision-making at all levels
Any reform has its greatest impact on patients and their providers of healthcare. Those with the most knowledge of the risks and benefits of change are doctors, nurses, allied healthcare professionals, and technical support staff actively involved in clinical care. Unless these clinicians are embedded in all decision-making processes, much potential benefit will be lost. Yes, there are managers with medical and nursing degrees, but if they are not practising clinicians their knowledge of what is needed and is appropriate at the coalface will be no greater than those with degrees of other sorts.
Auckland Hospital in Grafton. Photo / Sylvie Whinray
I am sure that some of the issues above are being addressed. Without this happening, the reforms will fail. One has to hope that those making the decisions have the intellect, experience, and common sense to achieve meaningful and lasting improvement in healthcare. Only time will tell.
In the meantime, patients will be referred to the hospital service, or come via the Emergency Department, and we will provide the best care possible given the available resources. They will then return to the community to be cared for by their GPs and a range of community-based healthcare providers. Paradoxically, while the health system is being turned upside down, in many ways, nothing changes.
* Dr Richard Frith is a semi-retired neurologist and clinical neurophysiologist in Auckland. He has had a number of clinical leadership roles in healthcare in New Zealand and Australia.
